You are the school nurse where Mrs. T. works. While at recess duty, another teacher runs up to you and reports that Mrs. T. is not acting like herself
Case Study: Mrs. T.
Directions: Read the case study below. Evaluate the information and formulate a conclusion based on your evaluation. Complete the critical thinking table and submit this completed template to the assignment dropbox.
Case Study: Mrs. T.
It is necessary for an RN-BSN-prepared nurse to demonstrate an enhanced understanding of the pathophysiological processes of disease, the clinical manifestations and treatment protocols, and how they affect clients across the life span.
Evaluate the Health History and Medical Information for Mrs. T., presented below.
Health History and Medical Information
Mrs. T., a 42-year-old female, has been living at home with her two high school age children, husband, and dog. She is a schoolteacher who works full-time teaching at the local grade school. She tries to be active by walking with her husband and dog for 20 minutes on the weekend but is starting to add weight as she gets older. She has no known allergies. She is a pack-a-day smoker and drinks three glasses of wine/per night after work. She tries to eat healthy but likes to eat out at fast food restaurants to avoid having to cook.
Medical history includes atrial fibrillation controlled with beta blocker, hypercholesterolemia, mild anemia related to heavy menses, and migraines. Current medications include:
- Metoprolol 50mg daily
- Pravastatin 40 mg at bedtime daily for cholesterol
- Birth control pill Microgestin Fe in the AM
- Amitriptyline 20 mg/daily for migraines
Case Scenario
You are the school nurse where Mrs. T. works. While at recess duty, another teacher runs up to you and reports that Mrs. T. is not acting like herself. When you approach, you see her sitting on a bench mumbling something to the kids gathered around her. She has dropped her cell phone on the ground, and her right arm appears limp. You try asking her questions and you notice the right side of her face is slacken, and she does not seem to be making sense when talking.
You call an ambulance, and try to walk her back to your office, but she does not move well. You reassure her and try to determine if anything occurred prior to her loss of speech and movement. The other teachers say it came on suddenly, within the last 5 minutes. Mrs. T. shakes her head no to pain.
Objective Data – Completed by Ambulance Personal:
- Temperature: 36.5 degrees C
- BP 184/92, HR 101, RR 24, Pox 99%
- Blood Glucose = 107
- Positive FAST & VAN score, NIHSS = 12
- Height: 62 inches; Weight 89 kg
Laboratory/Test Results – On Arrival to the Emergency Department (Initial Results)
- WBC: 9.4 (1,000/uL)
- INR – 0.7
- CT Head is normal.
- Negative pregnancy test
- Cholesterol – 247, Triglycerides – 302
Expert Answer and Explanation
Critical Thinking Table
| Clinical Manifestations
Describe the clinical manifestations present in Mrs. T., focusing on what is normal and abnormal and how this relates to her current condition. |
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| Subjective | These include the manifestations that influenced the patient’s decisions to go for care. One of these manifestations is impaired ambulation considering that Mrs. T needs assistance to walk back to the office (Tavares et al., 2022).
She also experiences facial droop which is characterized by asymmetrical appearance of the face, signifying possible cerebrovascular accident. In addition, the patient exhibits signs of impaired mental capacity considering that she mumbles when talking. Furthermore, she drops the phone, signifying decline in motor control ability (Khan et al., 2022). These are abnormal manifestations that are common with patients with ischemic stroke which is characterized by the decline in the supply of blood to the brain, altering the brain’s capacity to coordinate movement, and communicate messages to and from other parts of the body. |
| Objective | Mrs. T’s objective data include:
Elevation of levels of cholesterol which is associated with cardiac disorders like Atrial Fibrillation (AF). Having AF is a risk factor for stroke. Normal body temperatures, signifying that the patient is experiencing adequate temperature control. The 24 RR is higher than the normal RR which ranges between 12 and 20. This is an indication of increase in demand for respiration. Abnormal heart rate levels signify stress which could be a response to stroke (von Rennenberg et al., 2021). The patient’s risk of developing stroke is high because she is hypertensive. |
| Primary and Secondary Diagnoses
Discuss the primary and secondary medical diagnoses that should be considered for Mrs. T., and why you chose this diagnosis. |
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| Primary medical diagnosis and why you chose this diagnosis. | The ischemic stroke: The 12 Van Score, NIHSS is an indication of positive diagnosis for this disorder. Also, the FAST test confirms these results.
Mrs. T is hypertensive, raising her risk of developing stroke. This condition may also worsen the clinical manifestations linked to stroke. |
| Secondary medical diagnosis and why you chose this diagnosis. | Hypercholesterolemia: With the elevation of the patient’s cholesterol, the cholesterol may form plague inside the arteries, disrupting the flow of blood (Patil et al., 2022). Also, the formation of thrombus is another potential risk because Mrs. T has atrial fibrillation.
As a serial smoker, Mrs. T risks developing serious cardiac problems, potentially increasing her risk of stroke. |
| Formulate a nursing diagnosis from the medical diagnoses | Immobility due to ischemic stroke is a nursing diagnosis for Mrs. T. This diagnosis is based on the screening and assessment results. A key aspect of this diagnosis it that it considers mobility as a critical need. Addressing this issue is necessary to help her avoid adverse health events that are likely to occur with prolonged use of wheelchairs (Yang et al., 2020). The pressure sores are some of these serious events. Focusing on this nursing need is crucial because it helps rehabilitate Mrs. T. |
| Pathophysiological Changes
Explain the pathophysiological changes in Mrs. T. |
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| What pathophysiological changes would you expect to be happening to Mrs. T.? | Given her past AF diagnosis, Mrs. T is likely to experience a slowdown of the blood flow to the atrium, resulting to clotting of the blood. The clotted blood would disrupt the flow of the blood to her brain if it finds its way to the brain.
With the surge in Mrs. T’S BP, her blood vessels become narrower, exacerbating the effects of the buildup of plague in these vessels. With lifestyle habits like heavy smoking and drinking, the patient’s BP may rise to serious levels, increasing the risk of stroke. |
| How will pathophysiological changes transition in the subacute phase after diagnosis and initial treatment? | Initially, the dysfunction of the patient’s neurological functioning would occur with the impaired flow of blood to the brain, which also causes stroke (Yoo & Lim, 2022). Following the diagnosis, and after receiving the necessary intervention, Mrs. T.’s body begins a process of recovery. Part of this process involves repair of the neurons coupled by improvement in cardiac functioning to enhance the supply of blood to the brain. |
| Health Status Effect
Describe the effects Mrs. T.’s current health status may have on her. |
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| Describe the physical, psychological, and emotional effects Mrs. T.’s current health status may have on her. | Considering the symptoms that Mrs. T presents with, she may struggle with performing ADLs , making her depend on others. For the patient, seeing her health deteriorate may cause her to develop stress (Kavga et al., 2021). Because the disease limits her from socializing or interacting with others, she may struggle emotionally. |
| Discuss the impact it can have on her role in the family. | For Mrs. T’s family, caring for her can be a burden especially if she is unable to perform ADLs. If her family depends on her for financial support, it may struggle financially. |
| Treatments and Support
Discuss treatments and support that can be completed for Mrs. T. |
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| Discuss the immediate treatments that can be completed for Mrs. T. | Addressing the patient’s immediate needs is necessary, and this would require activating the stroke protocol by immediately screening the patient, and initiating treatment. In case the patient is diagnosed with clotting problem, administering the thrombolytic therapy is crucial to resolve the problem (Tiwari et al., 2021). During this phase, it is equally important to manage the patient’s BP. |
| Describe the long-term support she may need to return to baseline activity level. | Long-term interventions for Mrs. T would involve the implementation of measures aimed at minimizing the chances of recurrence of the stroke. Part of these measures would include health education with emphasis on exercise and nutrition. The goal is to rehabilitate the patient, improving their independence in terms of how they manage their health. |
| Explain how the interdisciplinary team is utilized to help her family support and cope with her diagnosis. | The role of the interdisciplinary team is crucial when it comes to helping her family deal with negative emotions of seeing their kin struggle with stroke. The physical therapists provide the family with information on how to support their kin to achieve normal mobility. The social workers counsel the family, and recommends resources that can help the family members to deal with stress. On their part, the physician conducts follow-up, advising the family on how to support the patient. |
References
Kavga, A., Kalemikerakis, I., Faros, A., Milaka, M., Tsekoura, D., Skoulatou, M., Tsatsou, I., & Govina, O. (2021). The Effects of Patients’ and Caregivers’ Characteristics on the Burden of Families Caring for Stroke Survivors. International journal of environmental research and public health, 18(14), 7298. https://doi.org/10.3390/ijerph18147298.
Khan, F., Abusharha, S., Alfuraidy, A., Nimatallah, K., Almalki, R., Basaffar, R., Mirdad, M., Chevidikunnan, M. F., & Basuodan, R. (2022). Prediction of Factors Affecting Mobility in Patients with Stroke and Finding the Mediation Effect of Balance on Mobility: A Cross-Sectional Study. International journal of environmental research and public health, 19(24), 16612. https://doi.org/10.3390/ijerph192416612.
Patil, S., Darcourt, J., Messina, P., Bozsak, F., Cognard, C., & Doyle, K. (2022). Characterising acute ischaemic stroke thrombi: insights from histology, imaging and emerging impedance-based technologies. Stroke and vascular neurology, 7(4), 353–363. https://doi.org/10.1136/svn-2021-001038.
Tavares, E., Coelho, J., Rogado, P., Correia, R., Castro, C., & Fernandes, J. B. (2022). Barriers to Gait Training among Stroke Survivors: An Integrative Review. Journal of functional morphology and kinesiology, 7(4), 85. https://doi.org/10.3390/jfmk7040085.
Tiwari, S., Joshi, A., Rai, N., & Satpathy, P. (2021). Impact of Stroke on Quality of Life of Stroke Survivors and Their Caregivers: A Qualitative Study from India. Journal of neurosciences in rural practice, 12(4), 680–688. https://doi.org/10.1055/s-0041-1735323.
von Rennenberg, R., Krause, T., Herm, J., Hellwig, S., Scheitz, J. F., Endres, M., Haeusler, K. G., & Nolte, C. H. (2021). Heart Rate Variability and Recurrent Stroke and Myocardial Infarction in Patients With Acute Mild to Moderate Stroke. Frontiers in neurology, 12, 772674. https://doi.org/10.3389/fneur.2021.772674.
Yang, K. L., Chen, L., Kang, Y. Y., Xing, L. N., Li, H. L., Cheng, P., & Song, Z. H. (2020). Identification of risk factors of developing pressure injuries among immobile patient, and a risk prediction model establishment: A protocol for systematic review. Medicine, 99(52), e23640. https://doi.org/10.1097/MD.0000000000023640.
Yoo, Y. J., & Lim, S. H. (2022). Assessment of Lower Limb Motor Function, Ambulation, and Balance After Stroke. Brain & NeuroRehabilitation, 15(2), e17. https://doi.org/10.12786/bn.2022.15.e17.
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